<div>
  <div>
    Client information
  </div>

  <div>
    Client name
    <input type="text" id="ClientName" class=""/>
  </div>

  <div>
    Insurance Company
    <input type="text" id="InsuranceCompany" class=""/>
  </div>

  <div>
    Policy number
    <input type="text" id="PolicyNumber" class=""/>
  </div>

  <div>
    Effective date
    <input type="text" id="EffectiveDate" class=""/>
  </div>

  <div>
    Date of Initial process
    <input type="text" id="InitDate" class=""/>
  </div>

  <div>
    Date last modified
    <input type="text" id="ModifiedDate" class=""/>
  </div>

  <div>
    Policy cost
    <input type="text" id="PolicyCost" class=""/>
  </div>

  <div>
    Total Fees & Charges
    <input type="text" id="Fees" class=""/>
  </div>

  <div>
    Total Policy Cost
    <input type="text" id="TotalPolicyCost" class=""/>
  </div>

  <div>
    Suffix
    <input type="text" id="Suffix" class=""/>
  </div>

  <div>
    First Name
    <input type="text" id="FirstName" class=""/>
  </div>

  <div>
    MiddleN ame
    <input type="text" id="MiddleName" class=""/>
  </div>

  <div>
    Last Name
    <input type="text" id="LastName" class=""/>
  </div>

  <div>
    Gender
    <input type="text" id="Gender" class=""/>
  </div>

  <div>
    MatrialStatus
    <input type="text" id="MatrialStatus" class=""/>
  </div>

  <div>
    Date of birth
    <input type="text" id="BirthDate" class=""/>
  </div>

</div